1. Incident Name 2. Operational Period to be covered … Action Plan.pdf1. Incident Name 2....

CG IAP COVER SHEET (Rev 4/04)

1. Incident Name

2. Operational Period to be covered by IAP (Date/Time)

From: To:

CG IAP COVER SHEET

3. Approved by Incident Commander(s):

ORG NAME

INCIDENT ACTION PLAN The items checked below are included in this Incident Action Plan:

ICS 202-CG (Response Objectives)

_________________________________________________________________________________________________

ICS 203-CG (Organization List) – OR – ICS 207-CG (Organization Chart)

_________________________________________________________________________________________________

ICS 204-CGs (Assignment Lists)

One Copy each of any ICS 204-CG attachments: _________________________________________________________________________________________________

ICS 205-CG (Communications Plan)

_________________________________________________________________________________________________

ICS 206-CG (Medical Plan)

ICS 208-CG (Site Safety Plan) or Note SSP Location ___________________________________________________

Map/Chart

Weather forecast / Tides/Currents

Other Attachments

4. Prepared by: Date/Time

INCIDENT BRIEFING ICS 201-CG (pg 1 of 4) (Rev 4/04)

1. Incident Name

2. Prepared by: (name)

Date: Time:

INCIDENT BRIEFING ICS 201-CG

3. Map/Sketch (include sketch, showing the total area of operations, the incident site/area, overflight results, trajectories, impacted shorelines, or other graphics depicting situational and response status)

4. Current Situation:


1. Incident Name


Date: Time:


5. Initial Response Objectives, Current Actions, Planned Actions


1. Incident Name


Date: Time:


6. Current Organization (fill in additional appropriate organization)

Safety Officer

Liaison Officer

Public Information Officer

Operations Section Planning Section Logistics Section Finance Section


1. Incident Name


Date: Time:


7. Resources Summary

Resource

Resource Identifier

Date Time

Ordered

On-

Scene ETA (X)

NOTES: (Location/Assignment/Status)

INCIDENT OBJECTIVES ICS 202-CG (Rev 4/04)

1. Incident Name

2. Operational Period (Date/Time)

From: To:

INCIDENT OBJECTIVES ICS 202-CG

3. Objective(s)

4. Operational Period Command Emphasis (Safety Message, Priorities, Key Decisions/Directions)

Approved Site Safety Plan Located at:

5. Prepared by: (Planning Section Chief) Date/Time

INCIDENT OBJECTIVES ICS 202-CG (Rev 4/04)

INCIDENT OBJECTIVES (ICS 202-CG) Purpose. The Incident Objectives form describes the basic incident strategy, control objectives, command emphasis/priorities, and safety considerations for use during the next operational period. Preparation. The Incident Objectives form is completed by the Planning Section following each Command and General Staff Meeting conducted in preparing the Incident Action Plan. Distribution. The Incident Objectives form will be reproduced with the IAP and given to all supervisory personnel at the Section, Branch, Division/Group, and Unit levels. All completed original forms MUST be given to the Documentation Unit. Item # Item Title Instructions 1. Incident Name Enter the name assigned to the incident. 2. Operational Period Enter the time interval for which the form applies. Record the start and end date

and time. 3. Objective(s) Enter clear, concise statements of the objectives for managing the response.

These objectives are for the incident response for this operational period and for the duration of the incident. Include alternatives.

4. Operational Period Enter clear, concise statements for safety message, priorities, Command Emphasis and key command emphasis/decisions/directions. Enter information such as

known safety hazards and specific precautions to be observed during this operational period. If available, a safety message should be referenced and attached. At the bottom of this box, enter the location where approved Site Safety Plan is available for review.

Site Safety Plan Note location of the approved Site Safety Plan. 5. Prepared By Enter the name of the Planning Section Chief completing the form. Date/Time Enter date (month, day, year) and time prepared (24-hour clock). NOTE: ICS 202-CG, Incident Objectives, serves as part of the Incident Action Plan (IAP)

ORGANIZATION ASSIGNMENT LIST ICS 203-CG (Rev 09/06)

1. Incident Name


From: To:

ORGANIZATION ASSIGNMENT LIST

ICS 203-CG

3. Incident Commander(s) and Staff 7. OPERATION SECTION

Agency IC Deputy Chief

Deputy

Deputy

Staging Area Manager



Safety Officer:

Information Officer:

Liaison Officer:

a. Branch – Division Groups

4. Agency Representatives Branch Director

Agency Name Deputy

Division Group

Division Group

Division Group

Division/Group

Division/Group

5. PLANNING/INTEL SECTION b. Branch – Division/Groups

Chief Branch Director

Deputy Deputy

Resources Unit Division/Group

Situation Unit Division/Group

Environmental Unit Division/Group

Documentation Unit Division/Group

Demobilization Unit Division/Group

Technical Specialists c. Branch – Division/Groups

Branch Director

Deputy

Division/Group

Division/Group

6. LOGISTICS SECTION Division/Group

Chief Division/Group

Deputy Division/Group

a. Support Branch d. Air Operations Branch

Director Air Operations Br. Dir

Supply Unit Helicopter Coordinator

Facilities Unit

Vessel Support Unit 8. FINANCE/ADMINISTRATION SECTION

Ground Support Unit Chief

Deputy

b. Service Branch Time Unit

Director Procurement Unit

Communications Unit Compensation/Claims Unit

Medical Unit Cost Unit

Food Unit

9. Prepared By: (Resources Unit) Date/Time

ORGANIZATION ASSIGNMENT LIST ICS 203-CG (Rev 09/06)

ORGANIZATION ASSIGNMENT LIST (ICS 203-CG) Instructions for filling out the form Purpose. The Organization Assignment List provides ICS personnel with information on the units that are currently activated and the names of personnel staffing each position/unit. It is used to complete the Incident Organization Chart (ICS form 207-CG) which is posted on the Incident Command Post display. An actual organization will be event-specific. Not all positions need to be filled. The size of the organization is dependent on the magnitude of the incident and can be expanded or contracted as necessary. Preparation. The Resources Unit prepares and maintains this list under the direction of the Planning Section Chief. Note: Depending on the incident, the Intelligence and Information function may be organized in several ways: 1) within the Command Staff as the Intelligence Officer; 2) As an Intelligence Unit in Planning Section; 3) As an Intelligence Branch or Group in the Operations Section; 4) as a separate General Staff Intelligence Section; and 5) as an Intelligence Technical Specialist. The incident will drive the need for the Intelligence and Information function and where it is located in the ICS organization structure. The Intelligence and information function is described in significant detail in NIMS and in the Coast Guard Incident Management Handbook (IMH). Distribution. The Organization Assignment List is duplicated and attached to the Incident Objectives form (ICS 202-CG) and given to all recipients of the Incident Action Plan. All completed original forms MUST be given to the Documentation Unit. Item # Item Title Instructions 1. Incident Name Enter the name assigned to the incident. 2. Operational Period Enter the time interval for which the form applies. Record the start and end date

and time. 3. Incident Commander Enter the names of the Incident Commander and Staff. Use at least the first initial and Staff and last name. 4. Agency Representative Enter the agency names and the names of their representatives. Use at least the

first initial and last name. 5. Section Enter the name of personnel staffing each of the listed positions. Use at least the thru first initial and last name. For Units, indicate Unit Leader and for Divisions/ 8. Groups indicate Division/Group Supervisor. Use an additional page if more than

three branches are activated. If there is a shift change during the specified operational period, list both names, separated by a slash.

9. Prepared By Enter the name and position of the person completing the form Date/Time Enter date (month, day, year) and time prepared (24-hour clock).

ASSIGNMENT LIST ICS 204-CG (Rev 04/04)

1. Incident Name


From: To:

Assignment List ICS 204-CG

3. Branch

4. Division/Group/Staging

5. Operations Personnel Name Affiliation Contact # (s)

Operations Section Chief:

Branch Director:

Division/Group Supervisor/STAM:

6. Resources Assigned “X” indicates 204a attachment with additional instructions

Strike Team/Task Force/Resource Identifier Leader Contact Info. #

# Of Persons Reporting Info/Notes/Remarks

7. Work Assignments

8. Special Instructions

9. Communications (radio and/or phone contact numbers needed for this assignment)

Name/Function Radio: Freq./System/Channel Phone Cell/Pager

____

____

____

Emergency Communications

Medical Evacuation Other


11. Reviewed by (PSC): Date/Time

12. Reviewed by (OSC): Date/Time

ASSIGNMENT LIST ICS 204-CG (Rev 04/04)

ASSIGNMENT LIST (ICS 204-CG) Purpose. The Assignment List(s) informs Division and Group supervisors of incident assignments. Once the Unified Command and General Staff agree to the assignments, the assignment information is given to the appropriate Divisions and Groups. Preparation. The Assignment List is normally prepared by the Resources Unit, using guidance from the Incident Objectives (ICS 202-CG), Operational Planning Worksheet (ICS 215-CG), and the Operations Section Chief. The Assignment List must be approved by the Planning Section Chief and Operations Section Chief. When approved, it is included as part of the Incident Action Plan (IAP). Specific instructions for specific resources may be entered on an ICS 204a-CG for dissemination to the field. A separate sheet is used for each Division or Group. The identification letter of the Division is entered in the form title. Also enter the number (roman numeral) assigned to the Branch. Special Note. The Assignment List, ICS 204-CG submits assignments at the level of Divisions and Groups. The Assignment List Attachment, ICS 204a-CG shows more specific assignment information, if needed. The need for an ICS 204a-CG is determined by the Planning and Operations Section Chiefs during the Operational Planning Worksheet (ICS 215-CG) development. Distribution. The Assignment List is duplicated and attached to the Incident Objectives and given to all recipients of the Incident Action Plan. In some cases, assignments may be communicated via radio/telephone/fax. All completed original forms MUST be given to the Documentation Unit. Item # Item Title Instructions 1. Incident Name Enter the name assigned to the incident. 2. Operational Period Enter the time interval for which the form applies. 3. Branch Enter the Branch designator. 4. Division/Group/Staging Enter the Division/Group/Staging designator. 5. Operations Personnel Enter the name of the Operations Chief, applicable Branch Director, and Division

Supervisor. 6. Resources Assigned Each line in this field may have a separate Assignment List Attachment (ICS

204a-CG). Enter the following information about the resources assigned to Division or Group for this period:

Identifier List identifier Leader Leader name Contact Information Primary means of contacting this person (e.g., radio, phone, pager, etc.). Be sure

to include area code when listing a phone number. # Of Persons Total number of personnel for the strike team, task force, or single resource

assigned. Reporting Info/Notes/ Special notes or directions, specific to this strike team, task force, or single Remarks resource. Enter an "X" check if an Assignment List Attachment (ICS 204a-CG)

will be prepared and attached. The Planning and Operations Section Chiefs determine the need for an ICS 204a-CG during the Operational Planning Worksheet (ICS 215-CG) development.

7. Work Assignment Provide a statement of the tactical objectives to be achieved within the operational period by personnel assigned to this Division or Group.

8. Special Instructions Enter a statement noting any safety problems, specific precautions to be exercised, or other important information.

9. Communications Enter specific communications information (including emergency numbers) for this division /group. If radios are being used, enter function (command, tactical, support, etc.), frequency, system, and channel from the Incident Radio Communications Plan (ICS 205-CG). Note: Phone numbers should include area code.

10. Prepared By Enter the name of the person completing the form, normally the Resources Unit Leader.

Date/Time Enter date (month, day, year) and time prepared (24-hour clock). 11. Reviewed by (PSC) Date/Time Enter date (month, day, year) and time prepared (24-hour clock). 12. Reviewed by (OSC) Enter the name of the operations person reviewing the form, normally the

Operations Section Chief. Date/Time Enter date (month, day, year) and time prepared (24-hour clock).

1. Incident Name 2. Operational Period (Date / Time)

From: To: COMMUNICATIONS LIST

ICS 205A-CG

3. Basic Local Communications Information

Assignment Name Method(s) of contact (radio frequency, phone, pager, cell #(s), etc.)

4. Prepared by: (Communications Unit) Date / Time

COMMUNICATIONS LIST ICS 205a-CG (Rev. 07/04)

COMMUNICATIONS LIST (ICS 205a-CG) Special Note. This optional form is used in conjunction with the Incident Radio Communications Plan, ICS 205-CG. Whereas the ICS 205-CG is used to provide information on all radio frequencies down to the Division/Group level, the Communications List, ICS 205a-CG, lists methods of contact for personnel assigned to the incident (radio frequencies, phone numbers, pager numbers, etc.), and functions as an incident directory. Purpose. The Communications List records methods of contact for personnel on scene. Preparation. The Communications List can be filled out during check-in and is maintained and distributed by Communications Unit personnel. Distribution. The Communications List is distributed within the ICS and posted, as necessary. All completed original forms MUST be given to the Documentation Unit. Item # Item Title Instructions 1. Incident Name Enter the name assigned to the incident. 2. Operational Period Enter the time interval for which the form applies. 3. Basic Local Comms Enter the communications methods assigned and used for each Information assignment. Assignment Enter the ICS Organizational assignment. Name Enter the name of the contact person for the assignment. Method(s) of contact Enter the radio frequency, telephone number(s), etc. for each

assignment. 4. Prepared By Enter the name of the Communications Unit Leader preparing the form. Date/Time Enter date (month, day, year) and time prepared (24-hour clock).

1. Incident Name

2. Operational Period (Date / Time)

From: To:

INCIDENT RADIO COMMUNICATIONS PLAN ICS 205-CG

3. BASIC RADIO CHANNEL USE

SYSTEM / CACHE CHANNEL FUNCTION FREQUENCY ASSIGNMENT REMARKS

4. Prepared by: (Communications Unit) Date / Time

INCIDENT RADIO COMMUNICATIONS PLAN ICS 205-CG (Rev.07/04)

1. Incident Name


From: To: MEDICAL PLAN

ICS 206-CG

3. Medical Aid Stations

Name Location Contact # Paramedics On

site (Y/N)

4. Transportation

Ambulance Service Address Contact # Paramedics

On board (Y/N)

5. Hospitals

Hospital Name Address Contact # Travel Time Burn

Ctr? Heli- Pad? Air Ground

6. Special Medical Emergency Procedures

7. Prepared by: (Medical Unit Leader) Date/Time

8. Reviewed by: (Safety Officer) Date/Time

MEDICAL PLAN ICS 206-CG (Rev.07/04)

ICS-207-CG (Rev. 09/04)

1. Incident Name


From: To:

INCIDENT ORGANIZATION CHART ICS 207-CG

INCIDENT COMMAND INFORMATION OFFICER

FOSC

SOSC

RPIC

SAFETY OFFICER

LIAISON OFFICER

INVESTIGATORS

NRDA REPS.

AGENCY REPS.

OPERATIONS SECTION CHIEF

PLANNING SECTION CHIEF

LOGISTICS SECTION CHIEF

FINANCE/ADMIN SECTION CHIEF

STAGING AREA MANAGER

RECOVERY BRANCH DIRECTOR

EMERGENCY RESPONSE BRANCH DIRECTOR

AIR OPERATIONS BRANCH DIRECTOR

EMS GRUP SUPERVISOR

ON-WATER GROUP SUPERVISOR

SHORESIDE GROUP SUPERVISOR

DISPOSAL GROUP SUPERVISOR

DECON GROUP SUPERVISOR

DISPERSANT OPS GROUP SUPERVISOR

IN-SITU BURN OPS GROUP SUPERVISOR

SAR GROUP SUPERVISOR

SALVAGE/SOURCE CONTROL GROUP SUPERVISOR

FIRE SUPPRESSION GROUP SUPERVISOR

HAZMAT GROUP SUPERVISOR

PROTECTION GROUP SUPERVISOR

LAW ENFORCEMENT SUPERVISOR

AIR TACTICAL GP SUPERVISOR

HELIBASE MANAGER

FIXED-WING BASE COORDINATOR

AIR SUPPORT GP SUPERVISOR

WILDLIFE BRANCH DIRECTOR

RECOVERY OF SUPERVISOR

WILDLIFE REHAB GROUP SUPERVISOR

TECHNICAL SPECIALISTS

SITUATION UNIT LEADER

RESOURCE UNIT LEADER

DOCUMENTATION UNIT LEADER

DEMOBILIZATION UNIT LEADER

ENVIRONMENTAL UNIT LEADER

SUPPORT BRANCH DIRECTOR

SUPPLY UNIT LEADER

FACILITIES UNIT LEADER

VESSEL SUPPORT UNIT LEADER

GROUND SUPPORT UNIT LEADER

SERVICE BRANCH DIRECTOR

FOOD UNIT LEADER

MEDICAL UNIT LEADER

COMMUNICATIONS UNIT LEADER

Indicates initial contact point

COST UNIT LEADER

TIME UNIT LEADER

PROCUREMENT UNIT LEADER

COMPENSATION UNIT LEADER

Site Safety and Health Plan ICS-208-CG (rev 9/06)

Incident Name: Date/Time Prepared: Operational Period:

Purpose. The ICS Compatible Site Safety and Health Plan is designed for safety and health personnel that use the Incident Command System (ICS).

It is compatible with ICS and is intended to meet the requirements of the Hazardous Waste Operations and Emergency Response regulation (Title 29,

Code of Federal Regulations, Part 1910.120). The plan avoids the duplication found between many other site safety plans and certain ICS forms. It is

also in a format familiar to users of ICS. Although primarily designed for oil and chemical spills, the plan can be used for all hazard situations.

Questions on the document should be addressed to the Coast Guard Office of Incident Management and Preparedness (G-RPP).

Table of Forms

FORM NAME FORM # USE REQUIRED OPTIONAL ATTACHED

Emergency Safety and Response

Plan

A Emergency response phase (uncontrolled) X

Site Safety Plan B Post-emergency phase (stabilized, cleanup) X

Site Map C Post-emergency phase map of site and hazards X

Emergency Response Plan D Part of Form B, to address emergencies X

Exposure Monitoring Plan E Exposure monitoring Plan to monitor exposure X

Air Monitoring Log E-1 To log air monitoring data X*

Personal Protective Equipment F To document PPE equipment and procedures X*

Decontamination G To document decon equipment and procedures X*

Site Safety Enforcement Log H To use in enforcing safety on site X

Worker Acknowledgement Form I To document workers receiving briefings X

Form A Compliance Checklist J To assist in ensuring HAZWOPER compliance X

Form B Compliance Checklist K To assist in ensuring HAZWOPER compliance X

Drum Compliance Checklist L To assist in ensuring HAZWOPER compliance X

Other:

* Required only if function or equipment is used during a response

This Page Intentionally Left Blank

EMERGENCY SAFETY

and RESPONSE PLAN 1. Incident Name

2. Date/Time Prepared

3. Operational Period

4. Attachments: Attach MSDS for each

Chemical:

5. Organization IC/UC:

Safety:

Div/Group Supv:

Entry Team: Backup Team:

Decon Team:

6.a. Physical Hazards and

Protection

6.b. Confined Space Noise Heat Stress Cold Stress Electrical Animal/Plant/Insect Ergonomic Ionizing Rad

Slips/Trips/Falls Struck by Water Violence Excavation Biomedical waste and/or needles Fatigue Other (specify)

6.c.

Tasks & Controls

6d Entry

Permit

6.e.

Ventilate

6f.

Hearing

Protection

6g. Shoes

(type)

6.h.

Hard

Hats

6i.

Clothing

(cold wx)

6j.

Life

Jacket

6l. Work/

Rest (hrs)

6.m.

Fluids

(amt/time)

6.n. Signs

&

Barricade

6.p. Fall

Protect

6.q.

Post

Guards

6.r.

Flash

Protect

6.s.

Work

Gloves

6.t.

Other

7.a. Agent 7.b. Hazards 7.c. Target Organs 7.d. Exposure Routes 7.f. PPE 7.g. Type of PPE

Explosive

Flammable

Reactive

Biomedical

Toxic

Radioactive

Carcinogen

Oxidizer

Corrosive

Specify Other:

Eyes Nose Skin Ears

Central Nervous System

Respiratory Throat

Lungs Heart Liver

Kidney Blood Lungs

Circulatory Gastrointestinal

Bone Other Specify:

Inhalation

Absorption

Ingestion

Injection

Membrane

Face Shield

Eyes

Gloves

Inner Suit

Splash Suit

Level A Suit

SCBA APR

SAR

Cartridges

Fire Resistance

8. Instruments: 8.a. Action Levels

8.b. Chemical Name(s): 8.c. LEL/UEL

%

8.d. Odor Thresh

Ppm

8.e. Ceiling/ IDLH

8.f. STEL/TLV

8.g. Flash Pt/ Ignition Pt

(F or C)

8.h. Vapor Pressure

(mm)

8.i. Vapor Density

8.j. Specific Gravity

8.l. Boiling

Pt F or C

O2

CGI

Radiation

Total HCs

Colorimetric

Thermal

Other

ICS-208-CG SSP-A Page 1 (rev 9/06): Page of

EMERGENCY SAFETY and

RESPONSE PLAN (Cont) 1. Incident Name



4. Attachments: Attach MSDS for each Chemical

9. Decontamination:

Instrument Drop Off

Outer Boots/Glove Removal

Suit/Gloves/Boot Disposal

Suit Wash

Decon Agent: Water

Other

Specify:

Bottle Exchange

Outer Suit Removal

Inner Suit Removal

SCBA/Mask Removal

SCBA/Mask Rinse

Inner Glove Removal

Work Clothes Removal

Body Shower

Intervening Steps Specify:

10. Site Map. Include: Work Zones, Locations of Hazards, Security Perimeter, Places of Refuge, Decontamination Line, Evacuation Routes, Assembly Point, Direction of North

Attached, Drawn Below:

11.a. Potential Emergencies:

Fire

Explosion

Other

11.b. Evacuation Alarms:

Horn # Blasts

Bells #Rings

Radio Code

Other:

11.c Emergency Prevention and Evacuation Procedures:

Safe Distance:

12. a. Communications:

Radio Phone Other

12.b. Command #: 12.c. Tactical #: 12.d. Entry #:

13.a. Site Security:

Personnel Assigned

13.b. Procedures:

13.c. Equipment:

14.a. Emergency Medical:

Personnel Assigned

14.b. Procedures:

14.c Equipment:

15. Prepared by:

16. Date/Time Briefed:

ICS-208-CG SSP-A Page 2.

(rev 9/06): Page of

EMERGENCY SAFETY AND RESPONSE PLAN (ICS-208-CG SSP-A)

Purpose: The Emergency Safety and Response Plan provides the Safety Officer and ICS personnel a plan for safeguarding personnel during the

initial emergency phase of the response. It is only used during the emergency phase of the response, which is defined as a situation involving an

uncontrolled release. It is also intended to meet the requirements of the Hazardous Waste Operations and Emergency Response (HAZWOPER)

regulation, Title 29 Code of Federal Regulations Part 1910.120.

Preparation: The Safety Officer or his/her designated staff starts the Emergency Site Safety and Response Plan. They initially address the hazards

common to all operations involved in the response (initial site characterization). Outside support organizations must be contacted to ensure the plan

is consistent with other plans (local, state, other federal plans). Form ICS-208-CG SSP-G need not be completed if this form is used. When the

operation proceeds into the post-emergency phase (site stabilized and cleanup operations begun) forms ICS-208-CG SSP-B and ICS-208-CG SSP-G

should be used. For large incidents, the Emergency Site Safety and Response Plan complements the Incident Action Plan. For smaller incidents, the

Emergency Site Safety and Response Plan complements ICS-201.

Distribution: The Emergency Safety and Response Plan completed by the Safety Officer is forwarded to the Planning Section Chief. Copies are

made and attached to the Assignment List(s) (ICS Form 204). The Operations Section Chief, Directors, Supervisors or Leaders get a copy of the

plan. They must ensure it is available on site for all personnel to review. The Safety Officer is responsible for ensuring that the Emergency Site

Safety and Response Plan properly addresses the hazards of the operation. The Safety Officer accomplishes this through on site enforcement and

feedback to the operational units.

Instructions:

Item # Item Title Instructions

1 Incident Name Print the name assigned to the incident.

2 Date/Time Prepared Enter date (month, day, year) prepared.

3 Operational Period Enter the time interval for which the assignment applies.

4 Attachments Enter attachments. Material Safety Data Sheets are mandatory under 1910.120. Safe Work Practices may

also be attached.

5 Organization List the personnel responsible for these positions. IC and Safety Officer are mandatory.

6 Physical Hazards &

Protection

Check off the physical hazards at the site. Identify the major tasks involved in the response (skimming,

lightering, overpacking, etc.). Check off the controls that would be used to safeguard workers from the

physical hazards for each major task.

7 Chemical/Agent List the chemicals involved in the response. Chemicals may be listed numerically. Check off the hazards,

potential health effects, pathway of dispersion, and exposure route of the chemical. Numbers corresponding

to the chemical may be entered into the check blocks to differentiate. Check off the PPE to be used.

Identify the type of PPE selected (for example: gloves: butyl rubber).

8 Instruments Indicate the instruments being used for monitoring. List the action levels adjacent to the instruments being

used. Identify the chemicals being monitored (2). List the physical parameters of the chemicals. Use a

separate form for additional chemicals monitored.

EMERGENCY SAFETY AND RESPONSE PLAN (FORM ICS-208-CG SSP-A) (Instructions Continued)

9 Decontamination Check off the decontamination steps to be used. Numbers may be entered to indicate the preferred sequence.

Identify any intervening steps necessary on the form or in a separate attachment.

10 Site Map Draw a rough site map. Ensure all the information listed is identified on the map.

11 Potential

Emergencies

Identify any potential emergencies that may occur. If none, so state. Check off the appropriate alarms that

may be used. Identify emergency prevention and evacuation procedures in the space provided or on a

separate attached sheet.

12 Communications Indicate type of site communications (phone, radio). Indicate phone numbers or frequencies for the

command, tactical and entry functions.

13 Site Security Identify the personnel assigned. Identify security procedures in the space provided or on a separate attached

sheet. Identify the equipment needed to support security operations.

14. Emergency Medical Identify the personnel assigned. Identify emergency medical procedures in the space provided or on a

separate attached sheet. Identify the equipment needed to support security operations.

15. Prepared by: Enter the name and position of the person completing the worksheet.

16. Date/time briefed: Enter the date/time the document was briefed to the appropriate workers and by whom.

CG ICS SITE

SAFETY PLAN (SSP)

HAZARD

ID/EVAL/CONTROL

1. Incident Name



4. Safety Officer (include method of

contact)

5. Supervisor/Leader

6. Location and Size of Site

7. Site Accessibility

Land Water Air

Comments:

8. For Emergencies Contact:

9. Attachments: Attach MSDS for each

Chemical

10.a.

Job Task/Activity

10.b.

Hazards*

10.c. Potential Injury & Health

Effects

10.d. Exposure

Routes

10.e.

Controls: Engineering, Administrative, PPE

Inhalation

Absorption

Ingestion

Injection

Membrane

Inhalation

Absorption

Ingestion

Injection

Membrane

Inhalation

Absorption

Ingestion

Injection

Membrane

Inhalation

Absorption

Ingestion

Injection

Membrane

Inhalation

Absorption

Ingestion

Injection

Membrane

11. Prepared By:


*HAZARD LIST: Physical/Safety, Toxic, Explosion/Fire, Oxygen Deficiency,

Ionizing Radiation, Biological, Biomedical, Electrical, Heat Stress, Cold Stress,

Ergonomic, Noise, Cancer, Dermatitis, Drowning, Fatigue, Vehicle, & Diving

ICS-208-CG SSP-

B (rev 9/06): Page of

SITE SAFETY PLAN (FORM ICS-208-CG SSP-B)

Purpose: The Site Safety Plan provides the Safety Officer and ICS personnel a plan for safeguarding personnel during the post-emergency phase of an incident.

The post-emergency phase is when the situation is stabilized and cleanup operations have begun. ICS-208-CG SSP-B is intended to meet the requirements of the

Hazardous Waste Operations and Emergency Response (HAZWOPER) regulation, Title 29 Code of Federal Regulations Part 1910.120.

Preparation: The Safety Officer or his/her designated staff starts the Site Safety Plan. They initially address the hazards common to all operations involved in

the response (initial site characterization). The plan is then reproduced and as a minimum sent to ICS Group/Division Supervisors. They amend it according to

unique job or on-scene hazards with support from the Safety Officer and/or his/her staff (detailed site characterization). The plan is continuously updated to

address changing conditions. During the first hours of the response, where most response functions are in the emergency phase, the Safety Officer may chose to

use the Emergency Safety and Response Plan (ICS-208-CG SSP-A) in place of the Site Safety Plan. For large incidents, ICS-208-CG SSP-B compliments the

Incident Action Plan (IAP). For smaller incidents, ICS-208-CG SSP-B compliments ICS Form 201. The Safety Officer is encouraged to use the HAZWOPER

Compliance Checklist (Form ICS-208-CG SSP-K) to ensure the IAP and the 201 address the requirements and all other pertinent ICS forms (203, 205, 206, etc.)

are completed.

Distribution: The initial Site Safety Plan completed by the Safety Officer is forwarded to the Planning Section Chief. Copies are made and attached to the

Assignment List(s) (ICS Form 204). The Operations Section Chief, Directors, Supervisors or Leaders get a copy and make on site amendments specific to their

operation. They must also ensure it is available on site for all personnel to review. The Safety Officer provides personnel from his/her staff to assist in the detailed

site characterization. The Safety Officer is responsible for ensuring that the Site Safety Plan for each assignment properly addresses the hazards of the assignment.

The Safety Officer must ensure that the safety plans on site are consistent. The Safety Officer accomplishes this through on site enforcement and feedback to the

operational units.

Instructions:





4 Safety Officer Enter the name of the Safety Officer and means of contact.

5 Group/Division Supv

Strike Team/TF Leader

The Supervisor/Leader who receives this form will enter their name here.

6 Location & size of site Enter the geographical location of the site and the approximate square area.

7 Site Accessibility Check the block(s) if the site is accessible by land, water, air, etc.

8 For Emergencies

Contact

Enter the name and way to contact the individual who handles emergencies.

9 Attachments Enter attachments. Material Safety Data Sheets are mandatory under 1910.120. Safe Work Practices may

also be attached.

10 Job/Task Activity Enter Job/Task & Activities, list hazards, list potential injury and health effects, check exposure routes

and identify controls. If more detail is needed for controls, provided attachments.

11 Prepared by Enter the name and position of the person completing the worksheet.

12 Date/Time Briefed: Enter the date/time the document was briefed to the appropriate workers and by whom.

CG ICS SSP: SITE MAP 1. Incident Name


3. Operational

Period

4. Safety Officer (include method of contact)



7. Site Accessibility

Land Water Air

Comments:

8. For Emergencies

Contact:

9. Include:

- Work Zones - Locations of Hazards

- Security Perimeter - Places of Refuge

- Decontamination Line - Evacuation Routes

10. Sketch of Site:

Attached. Drawn Here

11. Prepared By:


HAZARD LIST: Physical/Safety, Toxic, Explosion/Fire, Oxygen

Deficiency, Ionizing Radiation, Biological, Biomedical, Electrical,

Heat Stress, Cold Stress, Ergonomic, Noise, Cancer, Dermatitis,

Drowning, Fatigue, Vehicle, & Diving

ICS-208-CG SSP-C

(rev 9/06): Page of

SITE MAP FOR SITE SAFETY PLAN (ICS-208-CG SSP-C)

Purpose: The Site Map for the Site Safety Plan is required by Title 29 Code of Federal Regulations Part 1910.120. It provides in 1 place a visual

description of the site which can help ICS personnel locate hazards, identify evacuation routes and places of refuge.

Preparation: The Site Map for the Site Safety Plan can be completed by the Safety Officer, his/her staff or by ICS field personnel (Group

Supervisors, Task Force/Strike Team Leaders) working at a site with unique and specific hazards. One or several maps may be developed,

depending on the size of the incident and the uniqueness of the hazards. The key is to ensure that the workers using the map(s) can clearly identify

the work zones, locations of hazards, evacuation routes and places of refuge.

Distribution: This form must be located with the Site Safety Plan (ICS-208-CG SSP-B). It therefore follows the same distribution route.

Instructions:






5 Supervisor/Leader The Supervisor/Leader who receives this form will enter their name here.

6 Location & size of

site

Enter the geographical location of the site and the approximate square area.

7 Site Accessibility Check the block(s) if the site is accessible by land, water, air, etc.

8 For Emergencies

Contact


9 Include Ensure the map includes the listed items provided in this block.

10 Sketch of Site Sketch of site for work. May attach map or chart.



CG ICS SSP:

EMERGENCY

RESPONSE PLAN

1. Incident Name







8. Attachments: INCLUDE ICS FORM 206 and

EMT Medical Response Procedures

9. Emergency Alarm (sound

and location)

10. Backup Alarm (sound and

location)

11. Emergency Hand Signals 12. Emergency Personal Protective Equipment Required:

13. Emergency Notification Procedures

14. Places of Refuge (also see site map

form 208B)

15. Emergency Decon and Evacuation

Steps

16. Site Security Measures

17. Prepared By:

18. Date/Time Briefed: HAZARD LIST: Physical/Safety, Toxic, Explosion/Fire, Oxygen

Deficiency, Ionizing Radiation, Biological, Biomedical, Electrical, Heat

Stress, Cold Stress, Ergonomic, Noise, Cancer, Dermatitis, Drowning,

Fatigue, Vehicle, & Diving

ICS-208-CG SSP-D

(rev 9/06)

Page of

EMERGENCY RESPONSE PLAN (ICS-208-CG SSP-D)

Purpose: The Emergency Response Plan provides information on measures to be taken in the event of an emergency. It is used in conjunction with

the Site Safety Plan (Form ICS-208-CG SSP-B). It is also required by Title 29 Code of Federal Regulations Part 1910.120.

Preparation: The Safety Officer, his/her staff member or the Site Supervisor/Leader prepares the Emergency Response Plan. A copy of the

Medical Plan (ICS Form 206) must always be attached to this form.

Distribution: This form must be located with Site Safety Plan (ICS-208-CG SSP-B). It therefore follows the same distribution route.

Instructions:








site


7 For Emergencies

Contact


8 Attachments Enter attachments. ICS Form 206 must be included.

9 Emergency Alarm Enter a description of the sound of the emergency alarm and it’s location.

10 Backup Alarm Enter a description of the sound of the emergency alarm and it’s location.

11 Emergency Hand

Signals

Enter the emergency hand signals to be used.

12 Emergency Personal

Protective

Equipment Required

Enter the emergency personal protective equipment that may be needed in the event of an emergency.

13 Emergency

Notification

Procedures

Enter the procedures for notifying the appropriate personnel and organizations in the event of an emergency.

14 Places of Refuge Enter by name the place of refuge personnel can go to in the event of an emergency.

15 Emergency Decon &

Evacuation Steps

Enter emergency decontamination steps and evacuation procedures.

16 Site Security

Measures

Enter site security measures needed for emergencies.



15. Prepared By:

16. Date/Time Briefed: HAZARD LIST: Potential Health Effects: Bruise/Lacerations, Organ Damage, Central

Nervous System Effects, Cancer, Reproductive Damage, Low Back Pain, Temporary

Hearing Loss, Dermatitis, Respiratory Effects, Bone Breaks, & Eye Burning

18. Safety Officer Review:

Reporting: Monitoring results shall be logged in the ICS-208-CG SSP-E-1 form (Air Monitoring

Log) and attached as part of a current Site Safety Plan and Incident Action Plan. Significant

Exposures shall be immediately addressed to the IC and General Staff for immediate correction.

ICS-208-CG SSP-E

(rev 9/06) Page of

CG ICS SSP: Exposure

Monitoring Plan

1. Incident Name

2. Date/Time

Prepared:

3. Operational Period:

4. Safety Officer (Method of Contact):

5. Specific

Task/Operation

6. Survey

Location

7. Survey

Date/Time

8. Monitoring

Methodology

9. Direct-

Reading

Instrument

10. Air Sampling 11.

Hazard(s)

to Monitor

12.

Monitoring

Duration

13. Reasons to

Monitor

14. Laboratory

Support for

Analysis

Personal Breathing Zone

Area Air Monitoring Dermal Exposure Monitoring

Biological Monitoring:

Blood Urine

Other

Obtain bulk samples Other:

Model:

Manufacturer:

Last Mfr

Calibration Date:

Sampling/Analysis

Method:

Collecting Media: Charcoal Tube

Silica Gel

37 mm MCE Filter 37 mm PVC Filter

Other:____________

Regulatory

Compliance Assess current

PPE adequacy

Validate engineering controls

Monitor IDLH

Conditions Other_________

Personal Breathing Zone Area Air Monitoring

Dermal Exposure Monitoring

Biological Monitoring: Blood

Urine

Other Obtain bulk samples

Other:

Model:

Manufacturer:

Last Mfr

Calibration Date:

Sampling/Analysis

Method:


Silica Gel 37 mm MCE Filter

37 mm PVC Filter

Other:____________

Regulatory Compliance

Assess current

PPE adequacy Validate

engineering controls

Monitor IDLH Conditions

Other_________


Area Air Monitoring

Dermal Exposure Monitoring

Biological Monitoring:

Blood Urine

Other

Obtain bulk samples Other:

Model:

Manufacturer:

Last Mfr

Calibration Date:

Sampling/Analysis

Method:


Silica Gel

37 mm MCE Filter 37 mm PVC Filter

Other:____________

Regulatory

Compliance

Assess current

PPE adequacy

Validate engineering controls

Monitor IDLH

Conditions Other_________


Area Air Monitoring

Dermal Exposure Monitoring Biological Monitoring:

Blood

Urine Other

Obtain bulk samples

Other:

Model:

Manufacturer:

Last Mfr

Calibration Date:

Sampling/Analysis

Method:

Collecting Media: Charcoal Tube Silica Gel

37 mm MCE Filter

37 mm PVC Filter Other:____________

Regulatory

Compliance

Assess current PPE adequacy

Validate

engineering controls Monitor IDLH

Conditions

Other_________

EXPOSURE MONITORING PLAN (FORM ICS-208-CG SSP-E)

Purpose: The Exposure Monitoring Plan provides plan of monitoring conducted during an incident. The plan is a supplement to the Site Safety Plan

(ICS-208-CG SSP-B). It is only required when performing monitoring operations.

Preparation: The Safety Officer, his/her staff member or the Site Supervisor/Leader prepares the Exposure Monitoring Plan. If there is a decision

not to monitor during a response, the reasons must be stated clearly in the Site Safety Plan (ICS-208-CG SSP-B).


Instructions:






5 Specific Task /

Operation

Enter specific task or operation.

6 Survey Location Enter the location to be monitored.

7 Survey Date/Time Enter the date/time for the monitoring teams to survey.

8 Monitoring

Methodology

Enter/Check the monitoring method to be used.

9 Direct-Reading

Instrument

Enter the instrument model, manufacturer, last calibration date.

10 Air Sampling Enter Air Sampling analysis method

11 Hazards to Monitor Enter the hazards to monitor

12 Monitoring Duration Enter duration of monitoring

13 Reasons to Monitor Enter Reasons to Monitor

14 Laboratory Support for

Analysis

Enter Laboratory Support needed for analysis of samples


16 Date/Time Briefed Enter the date/time the document was briefed to the appropriate workers and by whom.

17 Safety Officer Review The Safety Officer must review and sign the form.

CG ICS SSP: AIR

MONITORING LOG

1. Incident Name

2. Date/Time

Prepared



5. Site Location

6. Hazards of Concern

7. Action Levels (include references):

8. Weather:

Temperature: Precipitation:

Wind:

Relative Humidity:

Cloud Cover:

9.a. Instrument, ID Number

Calibrated? Indicate below.

9.b. Monitoring Person Name(s) 9.c. Results (units) 9.d. Location 9.f. Time 9.g. Interferences and

Comments

10. Safety Officer Review:

Potential Health Effects: Bruise/Lacerations, Organ Damage, Central

Nervous System Effects, Cancer, Reproductive Damage, Low Back

Pain, Temporary Hearing Loss, Dermatitis, Respiratory Effects, Bone

Breaks, & Eye Burning

ICS-208-CG SSP-E-1

(rev 9/06): Page of

DAILY AIR MONITORING LOG (FORM ICS-208-CG SSP-E-1)

Purpose: The Exposure Monitoring Log provides documentation of air monitoring conducted during a spill. The log is a supplement to the Site

Safety Plan (ICS-208-CG SSP-B). It is only required when performing air monitoring operations. The information used from the log can help

update the Site Safety Plan.

Preparation: Persons conducting monitoring complete the Daily Air Monitoring Log. Normally these are air monitoring units under the Site Safety

Officer. If there is a decision not to monitor during a spill, the reasons must be stated clearly in the Site Safety Plan (ICS-208-CG SSP-B).

Distribution: The Daily Air Monitoring Log when completed is copied and forwarded to the Site Safety Officer who must review and sign the form.

The original form must be available on site, readily available and briefed to all impacted ICS personnel.

Instructions:







6 Hazards of Concern Enter the hazards being monitored.

7 Action Levels Enter the action levels/readings for the monitoring teams.

8 Weather Enter weather information. Ensure units of measure are listed.

9 Air Monitoring Data Enter the instrument type and number, persons monitoring, results with appropriate units, location of

reading, time of reading and interferences and comments.

10 Safety Officer Review The Safety Officer must review and sign the form.

CG ICS SSP: PERSONAL

PROTECTIVE

EQUIPMENT

1. Incident Name


3. Operational

Period




7. Hazards Addressed:


9. Equipment: 10. References Consulted:

11. Inspection Procedures:

12. Donning Procedures:

13. Doffing Procedures:

14. Limitations and Precautions (include

maximum stay time in PPE):

15. Prepared By:





Breaks, Eye Burning

ICS-208-CG SSP-F:

(Rev 9/06)

Page of

PERSONAL PROTECTIVE EQUIPMENT (ICS-208-CG SSP-F)

Purpose: The Personal Protective Equipment form is a list of personal protective equipment to be used in operations. The listing of personal

protective equipment is required by Title 29 Code of Federal Regulations Part 1910.120.

Preparation: The Personal Protective Equipment form is completed by the Site Safety Officer, or his/her staff. Personal protective equipment

common to all ICS Operations personnel is addressed first. Jobs with unique personal protective equipment requirements (fall protection) are

addressed next. When the form is delivered on site, the ICS Director, Supervisor, or Leader may amend the list to ensure personnel are adequately

protected from job hazards. It must be completed prior to the onset of any operations, unless addressed elsewhere by Standard Operating Procedures.


Instructions:








7 Hazard(s) Addressed: Enter the hazards that need to be safeguarded.

8 For Emergencies

Contact


9 Equipment List the equipment needed to address the hazards. If pre-designed Safe Work Practices are used, indicate here

and attach to form.

10 References consulted List the references used in making the selection for PPE.

11 Inspection Procedures Enter the procedures for inspecting the Personal Protective Equipment prior to donning. If pre-designed Safe

Work Practices are used, indicate here and attach to form.

12 Donning Procedures Enter the procedures for putting on the PPE. If pre-designed Safe Work Practices are used, indicate here and

attach to form.

13 Doffing Procedures Enter the information for removing the PPE. If pre-designed Safe Work Practices are used, indicate here and

attach to form.

14 Limitations and

Precautions

List the limitations and precautions when using PPE. Include the maximum time to be inside the PPE, Heat

Stress concerns, psychomotor skill detraction and other factors.



CG ICS SSP:

DECONTAMINATION

1. Incident Name


3. Operational

Period





8. Hazard(s) Addressed:

9. Equipment: 10. References Consulted:

11. Contamination Avoidance Practices:

12. Decon Diagram: Attached, Drawn below

13. Decon Steps

14. Prepared By:





Breaks, Eye Burning

ICS-208-CG SSP-G

(rev 9/06): Page of

DECONTAMINATION (ICS-208-CG SSP-G)

Purpose: The Decontamination form provides information on how workers can avoid contamination and how to get decontaminated. It is a

supplemental form to the Site Safety Plan.

Preparation: The Decontamination Form can be completed by the Site Safety Officer, a member of his/her staff or by the Group/Division

Supervisor, Task Force/Strike Team Leader on the site


Instructions:








7 For Emergencies

Contact


8 Hazard(s) Addressed: Enter the hazards that need to be safeguarded.

9 Equipment Enter the decontamination equipment needed for the site. If pre-designed Safe Work Practices are used,

indicate here and attach to this form.

10 References consulted List the references used in making the selection for PPE.

11 Contamination

Avoidance Practices

Enter procedures for personnel to avoid contamination. If pre-designed Safe Work Practices are used,

indicate here and attach to form.

12 Decon Diagram Draw a diagram for the decontamination operation. If pre-designed Safe Work Practices are used, indicate

here and attach to form.

13 Decon Steps List the decontamination steps.



CG ICS SSP:

ENFORCEMENT LOG

1. Incident Name






7. Attachments:

8.a. Job Task/Activity

8.b. Hazards

8.c. Deficiency

8.d. Action Taken

8.e. Safety Plan

Amended?

8.f. Signature of

Supervisor/Leader

9. Prepared By:

10. Date/Time Briefed: HAZARD LIST: Physical/Safety, Toxic, Explosion/Fire, Oxygen

Deficiency, Ionizing Radiation, Biological, Biomedical, Electrical, Heat

Stress, Cold Stress, Ergonomic, Noise, Cancer, Dermatitis, Drowning,

Fatigue, Vehicle, & Diving

ICS-208-CG SSP-H

(rev 9/06): Page of

SITE SAFETY ENFORCEMENT LOG (ICS-208-CG SSP-H)

Purpose: The Site Safety Plan Enforcement Log is used to help enforce safety during an incident.

Preparation: The Safety Officer and/or his/her staff complete the Site Safety Plan Enforcement Log. The log is completed as Safety personnel are

on scene reviewing the site. It should be completed at a minimum once per day. The number of enforcement logs to be completed depends on the

size of the incident. Enough should be completed to ensure that site safety is being adequately enforced.

Distribution: The Site Safety Plan enforcement log when completed is delivered to the Safety Officer. The Safety Officer can use the form to

amend the Site Safety Plan (ICS-208-CG SSP-A or B).

Instructions:





4 Safety Officer Enter the name of the Safety Officer and means of contact


6 For Emergencies

Contact


7 Attachments List any attached supporting documentation.

8 a Job/Task Activity Enter only those Job Task/activities for which a deficiency is noted.

8 b Hazards Enter the hazard not being sufficiently addressed.

8 c Deficiency Enter the deficiency.

8 d Action Taken Enter the corrective action taken to address the deficiency.

8 e Safety Plan Amended? Enter whether the on site safety plan was amended.

8 f Signature of

Supervisor/Leader

Ensure the Supervisor/Leader signs the form to acknowledge the deficiency.



CG ICS SSP WORKER

ACKNOWLEDGEMENT FORM

1. Incident Name

2. Site Location:

3. Attachments:

4. Type of Briefing 5. Presented By: 6. Date Presented 7. Time Presented

Safety Plan/Emergency Response Plan

Start Shift Pre-Entry

Exit End of Shift

Specify Other:

8.a. Worker Name (Print) 8.b. Signature* 8.c. Date 8.d. Time

* By signing this document, I am stating that I have read and fully understand

the plan and/or information provided to me.

ICS-208-CG SSP-I (rev 9/06): Worker Acknowledgement

Page of

WORKER ACKNOWLEDGEMENT FORM (ICS-208-CG SSP-I)

Purpose: The Worker Acknowledgement form is used to document workers who have received safety briefings.

Preparation: Those personnel responsible for conducting safety briefings complete this form initially. Once the briefings are completed, workers

who were briefed print their name, sign, date and indicate the time of the briefing.

Distribution: This form is returned to the Safety Officer or designated representative at the end of each operational period.

Instructions:

Item

#

Item Title Instructions


2 Site Location Indicate the location where the briefings are held.

3 Attachments Indicate any attachments used as part of the briefings.

4 Type of briefing Check the block next to the type of briefing.

5 Presented by Enter the name of the person conducting the briefing.

6 Date Presented Enter the date of the briefing.

7 Time Presented Enter the time of the briefing.

8 Worker Name, Signature,

Date and Time

Workers receiving the briefing print their name, sign, date and enter the time they acknowledge the

briefing.

CG ICS SSP: Emergency

Safety & Response Plan

1910.120 Compliance

Checklist (Form A)

1. Incident Name


3. Operational

Period

4. Site Supervisor/Leader

5. Location of Site

6.a. Cite: 1910.120 6.b. Requirement(sections that duplicate or explain are omitted) 6.c. ICS Form 6.d. Check 6.e. Comments

(q)(1) Is the plan in writing? SSP-A

(1) Is the plan available for inspection by employees? N/A Performance based

(q)(2)(i) Does the plan address pre-emergency planning and

coordination?

SSP-A

(ii) Does it address personnel roles? SSP-A

(ii) Does it address lines of authority? SSP-A

(ii) Does it address communications? SSP-A

(iii) Does it address emergency recognition? SSP-A

(iii) Does it address emergency prevention? SSP-A

(iv) Does it identify safe distances? SSP-A

(iv) Does it address places of refuge? SSP-A

(v) Does it address site security and control? SSP-A

(vi) Does it identify evacuation routes? SSP-A

(vi) Does it identify evacuation procedures? SSP-A

(vii) Does it address decontamination? SSP-A

(viii) Does it address medical treatment and first aid? SSP-A

(ix) Does it address emergency alerting procedures? SSP-A

(ix) Does it address emergency response procedures SSP-A

(x) Was the response critiqued? N/A Performance based

(xi) Does it identify Personal Protection Equipment? SSP-A

(xi) Does it identify emergency equipment? SSP-A

(q)(3)(ii) All the hazardous substances identified to the extent possible? N/A Performance based

(ii) All the hazardous conditions identified to the extent possible? N/A Performance based

(ii) Was site analysis addressed? N/A Performance based

(ii) Were engineering controls addressed? N/A Performance based

(ii) Were exposure limits addressed? N/A Performance based

(ii) Were hazardous substance handling procedures addressed? N/A Performance based

(iii) Is the PPE appropriate for the hazards identified? N/A Performance based

(iv) Is respiratory protection worn when inhalation hazards present? N/A Performance based

(v) Is the buddy system used in the hazard zone? N/A Performance based

(vi) Are backup personnel on standby? N/A Performance based

(vi) Are advanced first aid support personnel standing by? N/A Performance based

(vii) Has the ICS designated safety official been identified? SSP-A

(vii) Has the Safety Official evaluated the hazards? N/A Performance based

(viii) Can the Safety Official communicate with IC immediately? N/A Performance based

(ix) Are appropriate decontamination procedures implemented? N/A Performance based

ICS-208-CG SSP-J (rev 9/06) Page of

Emergency Safety & Response Plan Compliance Checklist Form A (ICS-208-CG SSP-J)

Purpose: The Emergency Safety and Response Plan 1910.120 Compliance Checklist is to ensure that incident response operations are in compliance

with Title 29, Code of Federal Regulations Part 1910.120, Hazardous Waste Operations and Emergency Response. It also identifies how form ICS-

208-CG SSP-J can be used to satisfy the HAZWOPER requirements. This checklist is an optional form.

Preparation: The Emergency Safety and Response Plan 1910.120 Compliance Checklist is completed by the Safety Officer or his/her staff as

frequently as necessary whenever the Safety Officer wants to ensure regulatory compliance. It is best used in conjunction with the Site Safety Plan

Enforcement Log (ICS-208-CG SSP-H). Many of the requirements are performance based and are best evaluated on scene by the Safety Officer or

his/her staff.

Distribution: The Safety Officer should maintain The Emergency Safety and Response Plan (ERP) 1910.120 Compliance Checklist.

Instructions:






5 Location of Site Enter the site location.

6 a Cites These are the regulatory cites within 1910.120. The major headings are highlighted in bold.

Informational cites or cites that are duplicative are not included.

6 b Requirement This lists the requirement in a question format. Some require documentation or some form of action.

6 c ICS Form Lists those requirements covered by ICS-208-CG SSP-A.

6 d Check Block Enter the check if the site satisfies the requirement.

6 f Comments This provides additional information on the requirement. The user may also enter comments.


CG ICS SSP: 1910.120

COMPLIANCE

CHECKLIST (Form B)

1. Incident Name


3. Operational

Period

4. Site Supervisor/Leader

5. Location of Site


1910.120 (b)(1)(ii)(A) Organizational structure? 203

(B) Comprehensive workplan? IAP Incident Action Plan

(C) Site Safety Plan? SSP-B

(D) Safety and health training program? N/A Responsibility of each employer

(E) Medical surveillance program? N/A Responsibility of each employer

(F) Employer SOPs? N/A Responsibility of each employer

(G) Written program related to site activities? N/A

(b)(1)(iii) Site excavation meets shored or slope requirements in 1926? N/A

(b)(2)(i)(D) Lines of communication? 201 203 205

(b)3(iv) Training addressed? N/A Responsibility of each employer

(v)-(vi) Information and medical monitoring addressed? N/A Responsibility of each employer

(b)4(i) Site Safety Plan kept on site? N/A

(ii)(A) Safety and health hazard analysis conducted? N/A

(B) Properly trained employees assigned to right jobs? N/A

(C) Personnel Protective Equipment issues addressed? SSP-F

(E) Frequency and types of air monitoring addressed? SSP-E

(F) Site control measures in place? SSP-B

(G) Decontamination procedures in place? SSP-G

(H) Emergency Response Plan in place? SSP-D

(I) Confined space entry procedures? SSP-B

(J) Spill containment program SSP-B

(iii) Pre-entry briefings conducted? SSP-I

(iv) Site Safety Plan effectiveness evaluated? SSP-H

(c)(1) Site characterization done? N/A

(c)(2) Preliminary evaluation done by qualified person? N/A

(c)(3) Hazard identification performed? SSP-B

(c)(4)(i) Location and size of site identified? SSP-B

(ii) Response activities, job tasks identified? SSP-B

(iii) Duration of tasks identified? SSP-B Operational period

(iv) Site topography and accessibility addressed? SSP-C

(v) Health and safety hazards addressed? SSP-B

(vi) Dispersion pathways addressed? SSP-B

(vii) Status and capabilities of medical emergency response teams? 206

(c)(5)(i)(iv) Chemical protective clothing addressed and properly selected? SSP-F

(ii) Respiratory protection addressed? SSP-B and F

(iii) Level B used for unknowns? N/A

ICS-208-CG SSP-K (rev 9/06): Page 1. Page of


COMPLIANCE

CHECKLIST Form B (cont)

1. Incident Name




1910.120 (c)(6)(i) Monitoring for ionization conducted? SSP-E

(ii) Monitoring conducted for IDLH conditions? SSP-E

(iii) Personnel looking out for dangers of IDLH environments? N/A

(iv) Ongoing air monitoring program in place? SSP-E

(c)(7) Employees informed of potential hazard occurrence? SSP-B

(c)(8) Properties of each chemical made aware to employees? SSP-B

(d)(1) Appropriate site control procedures in place? IAP, SSP-B

(d)(2) Site control program developed during planning stages? IAP, SSP-B

(d)(3) Site map, work zones, alarms, communications addressed? IAP, SSP-B

(g)(1)(i) Engineering, admin controls considered? SSP-B

(iii) Personnel not rotated to reduce exposures? N/A

(g)(5)(i) PPE selection criteria part of employer’s program? N/A Responsibility of employer

(ii) PPE use and limitations identified? SSP-F

(iii) Work mission duration identified? SSP-F

(iv) PPE properly maintained and stored? N/A Responsibility of employer

(vi) Are employees properly trained and fitted with PPE? N/A Responsibility of employer

(vii) Are donning and doffing procedures identified? SSP-F

(viii) Are inspection procedures properly identified? SSP-F

(ix) Is a PPE evaluation program in place? SSP-F

(h) (3) Periodic monitoring conducted? SSP-E

(k)(2)(i) Have decontamination procedures been established? SSP-G

(ii) Are procedures in place for contamination avoidance? SSP-G

(iii) Is personal clothing properly deconned prior to leaving the

site?

SSP-G

(iv) Are decontamination deficiencies identified and corrected? SSP-H

(k)(3) Are decontamination lines in the proper location? SSP-C

(k)(4) Are solutions/equipment used in decon properly disposed of? N/A

(k)(6) Is protective clothing and equipment properly secured? N/A

(k)(7) If cleaning facilities are used, are they aware of the hazards? N/A

(k)(8) Have showers and change rooms provided, if necessary? N/A

(l)(1)(iii) Are provisions for reporting emergencies identified? SSP-D

(iv) Are safe distances and places of refuge identified? SSP-B and C

(v) Site security and control addressed in emergencies? SSP-D

(vi) Evacuation routes and procedures identified? SSP-D

(vii) Emergency decontamination procedures developed? SSP-D

(ix) Emergency alerting and response procedures identified? SSP-D

(x) Response teams critiqued and followup performed? SSP-H

(xi) Emergency PPE and equipment available? SSP-D



COMPLIANCE

CHECKLIST Form B (cont)

1. Incident Name



6.a. Cite: 6.b. Requirement(sections that duplicate or explain are omitted) 6.c. ICS

Form

6.d. Check 6.e. Comments

1910.120 (l)(3)(i) Emergency notification procedures identified? SSP-D

(ii) Emergency response plan separate from Site Safety Plan? SSP-D

(iii) Emergency response plan compatible with other plans? SSP-D

(iv) Emergency response plan rehearsed regularly? SSP-D

(v) Emergency response plan maintained and kept current? SSP-H

1910.165 (b)(2) Can alarms be seen/heard above ambient light and noise

levels?

N/A

(b)(3) Are alarms distinct and recognizable? N/A

(b)(4) Are employees aware of the alarms and are they accessible? SSP-D

(b)(5) Are emergency phone numbers, radio frequencies clearly

posted?

206

(b)(6) Signaling devices in place where there are 10 or more workers? IAP

(c)(1) Are alarms like steam whistles, air horns being used? IAP

(d)(3) Are backup alarms available? IAP

(m) Are areas adequately illuminated? IAP

(n)(1)(i) Is an adequate supply of potable water available? IAP

(ii) Are drinking water containers equipped with a tap? IAP

(iii) Are drinking water containers clearly marked? IAP

(iv) Is a drinking cup receptacle available and clearly marked? IAP

(n)(2)(i) Are non-potable water containers clearly marked? IAP

(n)(3)(i) Are their sufficient toilets available? IAP

(n)(4) Have food handling issues been addressed? IAP

(n)(6) Have adequate wash facilities been provided outside hazard

zone?

IAP

(n)(7) If response is greater than 6 months, have showers been

provided?

IAP

7. Prepared By:


HAZWOPER 1910.120 COMPLIANCE CHECKLIST FORM B (ICS-208-CG SSP-K)

Purpose: The HAZWOPER 1910.120 Compliance Checklist is to ensure that incident response operations are in compliance with Title 29, Code of

Federal Regulations Part 1910.120, Hazardous Waste Operations and Emergency Response. It also identifies how other ICS forms can be used to

satisfy the HAZWOPER requirements. This is an optional form.

Preparation: The HAZWOPER 1910.120 Compliance Checklist is completed by the Safety Officer or his/her staff as frequently as necessary

whenever the Safety Officer wants to ensure regulatory compliance. It is best used in conjunction with the Site Safety Plan Enforcement Log (ICS-

208-CG SSP-H). The Site Safety Plan Forms (A-G) best meet some of the requirements. The Incident Action Plan is suited to address other

requirements, and the Safety Officer should ensure the IAP addresses them. Other requirements are performance based and are best evaluated on

scene by the Safety Officer or his/her staff.

Distribution: The HAZWOPER 1910.120 Compliance Checklist should be maintained by the Safety Officer.

Instructions:



2 Date/Time

Prepared

Enter date (month, day, year) prepared.



5 Location of Site Enter the site location.

6.a. Cites These are the regulatory cites within 1910.120. The major headings are highlighted in bold. Informational

cites or cites that are duplicative are not included.

6.b. Requirement This lists the requirement in a question format. Some require documentation or some form of action.

6.c. ICS Form Lists those ICS Forms that cover the requirement. IAP designations means it should be covered in IAP, it

does not guarantee it is covered. The Safety Officer must ensure this.

6.d. Check Block Enter the check if the site satisfies the requirement.

6.e. Comments This provides information on where else the requirement may be met. The user may also enter comments.



DRUM COMPLIANCE

CHECKSHEET

1. Incident Name


3. Operational

Period





8. Note: tanks and vaults should also be treated in the

same manner as described below [1910.120(j)(9)].

Many can also pose confined space hazards.

9.a. Cite: 1910.120 (Cites

that duplicate or explain

requirements are omitted)

9.b. Requirement

9.c. Check

9.d. Comments

(j)(1)(ii) Drums meet DOT, OSHA, EPA regs for waste they contain, including shipment?

(iii) Drums inspected and integrity ensured prior to movement?

(iii) Or drums moved to an accessible location (staging area) prior to movement?

(iv) Unlabelled drums treated as unknown until properly identified and labeled?

(v) Site activities organized to minimize drum handling?

(vi) Employers properly warned about the hazards of moving and handling drums?

(vii) Suitable overpack drums are available for addressing leaking and ruptured drums?

(viii) Leaking materials from drums properly contained?

(ix) Are drums that cannot be moved, emptied of contents with transfer equipment?

(x) Are suspect buried drums surveyed with underground detection system?

(xi) Are soil and covering material above buried drums removed with caution?

(xii) Is the proper extinguishing equipment on scene to control incipient fires?

(j)(2)(i) Are airlines on supplied air systems protected from leaking drums?

(ii) Are employees at a safe distance, using remote equipment, when handling explosive drums?

(iii) Are explosive shields in plane to protect workers opening explosive drums?

(iv) Is response equipment positioned behind shields when shields are used?

(v) Are non-sparking tools used in flammable or potentially flammable atmospheres?

(vi) Are drums under extreme pressure opened slowly & workers protected by shields/distance?

(vii) Are workers prohibited from standing and working on drums?

(j)(3) Is the drum handling equipment positioned and operated to minimize sources of ignition?

(j)(5)(i) For shock sensitive drums, have all non-essential employees been evacuated?

(ii) For shock sensitive drums: is handling equipment provided with shields to protect workers?

(iii) Are alarms that announce start/finish of explosive drum handling actions in place?

(iv) Are continuous communications in place between the drum handling site & command post?

(v) Are drums under pressure properly controlled for prior to handling?

(vi) Are drums containing packaged laboratory wastes treated as shock sensitive?

(j)(6)(i) Are lab packs opened by trained and experienced personnel?

(ii) Are lab packs showing crystallization treated as shock sensitive?

(j)(8)(ii-iii) Are drum staging areas manageable with marked access and egress?

(iv) Is bulking of drums conducted only after drum contents have been properly identified?

10. Prepared By:

Form SSP-L (rev 9/06) Page of

HAZWOPER 1910.120 DRUM COMPLIANCE CHECKLIST (ICS-208-CG SSP-L)

Purpose: The HAZWOPER 1910.120 Drum Compliance Checklist is to ensure that incident response operations are in compliance with Title 29,

Code of Federal Regulations Part 1910.120, Hazardous Waste Operations and Emergency Response whenever drums are encountered during an

incident. This is an optional form.

Preparation: The HAZWOPER 1910.120 Drum Compliance Checklist is completed by the Safety Officer or his/her staff as frequently as necessary

whenever the Safety Officer wants to ensure regulatory compliance. It is best used in conjunction with the Site Safety Plan Enforcement Log (ICS-

208-CG SSP-H). The Site Safety Plan Forms (A-G) best meet some of the requirements. Other requirements are performance based and are best

evaluated on scene by the Safety Officer or his/her staff.

Distribution: The HAZWOPER 1910.120 Drum Compliance Checklist should be maintained by the Safety Officer.

Instructions:








site


7 For Emergencies

Contact


8 Note Tanks and vaults should also be treated in the same manner as described in the checklist (1910.120((j)(9)).

9.a. Cites These are the regulatory cites within 1910.120. The major headings are highlighted in bold. Informational

cites or cites that are duplicative are not included.

9.b. Requirement This lists the requirement in a question format. Some require documentation or some form of action.

9.c. Check Block Enter the check if the site satisfies the requirement.

9.d. Comments This provides information on where else the requirement may be met. The user may also enter comments.


ICS-209-CG INCIDENT STATUS SUMMARY Page 1 of __ (Rev 06/05)

1. Incident Name

2. Operational Period (Date / Time) From: To: Time of Report

|

INCIDENT STATUS SUMMARY ICS 209-CG

3. Type of Incident Oil Spill HAZMAT AMIO SAR/Major SAR T SI/Terrorism Natural Disaster Marine Disaster Civil Disturbance Military Outload Planned Event Maritime HLS/Prevention

4. Situation Summary as of Time of Report:

5. Future Outlook/Goals/Needs/Issues:

6. Safety Status/Personnel Casualty Summary

Since Last Report Adjustments To Previous Op Period

Total

Responder Injury

Responder Death

Public Missing (Active Search)

Public Missing (Presumed Lost)

Public Uninjured

Public Injured

Public Dead

Total Public Involved

7. Property Damage Summary

Vessel $

Cargo $

Facility $

Other $

8. Attachments with clarifying information Oil/HAZMAT SAR/LE Marine Disaster Civil Disturbance Military Outload

ICS-209-CG INCIDENT STATUS SUMMARY Page 2 of __ (Rev 06/05)

9. Equipment Resources

Kind Notes # Ordered

# Available

# Assigned

# Out of Service

USCG Assets

Aircraft – Helo

Aircraft – Fixed Wing

Vessels – USCG Cutter

Vessels – Boat

Vehicles – Car

Vehicles – Truck

Pollution Equip – VOSS/SORS

Pollution Equip – Portable Storage

Pollution Equip – Boom

Non-CG/Other Assets

Aircraft – Helo

Aircraft – Fixed Wing

Vessels – SAR/LE Boat

Vessels – Work/Crew Boat

Vessels – Tug/Tow Boat

Vessels – Pilot Boat

Vessels – Deck Barge

Vessels –

Vehicles – Car

Vehicles – Ambulance

Vehicles – Truck

Vehicles – Fire/Rescue/HAZMAT

Vehicles – Vac/Tank Truck

Vehicles –

Pollution Equip – Skimmers

Pollution Equip – Tank Vsl/ Barge

Pollution Equip – Portable Storage

Pollution Equip – OSRV

Pollution Equip – Boom

Pollution Equip –

10. Personnel Resources

Agency Total # of People

USCG

DHS (other than USCG)

NOAA

FBI

DOD (USN Supsalv, CST, etc.)

DOI (US Fish & Wildlife, Nat Parks, BLM, etc.)

RP

State

Local

Total Personnel Resources Used From all Organizations:

11. Prepared by:

Date/Time Prepared:

ICS-209-CG INCIDENT STATUS SUMMARY Page __ of __ (Rev 06/05)

1. Incident Name


|

ICS 209-CG OIL/HAZMAT ATTACHMENT

3. HAZMAT/Oil Spill Status (Estimated, in gallons)

Common Name(s):

UN Number: Secured Unsecured

CAS Number: Remaining Potential (bbl):

Rate of Spillage (bbl/hr):

Adjustments To Previous Operational Period

Since Last Report Total

Volume Spilled/Released

Mass Balance - HAZMAT/Oil Budget

Recovered HAZMAT/Oil

Evaporation/Airborne

Natural Dispersion

Chemical Dispersion

Burned

Floating, Contained

Floating, Uncontained

Onshore

Total HAZMAT/Oil accounted for: N/A N/A

Comments:

4. HAZMAT/Oil Waste Management (Estimated, Since Last Report)

Recovered Disposed Stored

HAZMAT/Oil (bbl)

Oily Liquids (bbl)

Liquids (bbl)

Oily Solids (tons)

Solids (tons)

Comments:

5. HAZMAT/Oil Shoreline Impacts (Estimated in miles)

Degree of Impact Affected Cleaned To Be Cleaned

Light

Medium

Heavy

Total

Comments:

6. HAZMAT/Oil Wildlife Impacts (Since Last Report)

Died in Facility

Type of Wildlife Captured Cleaned Released DOA Euthanized Other

Birds

Mammals

Reptiles

Fish

Total

Comments:

7. Prepared by:

Date/Time Prepared:

ICS-209-CG INCIDENT STATUS SUMMARY Page __ of __ (Rev 06/05)

1. Incident Name


|

ICS 209-CG SAR/LE ATTACHMENT

3. Evacuation Status

Since Last Report Adjustments To Previous Operational Period

Total

Total to be Evacuated

Number Evacuated

4. Migrant Interdiction Status

Since Last Report Adjustments To Previous Op Period

Total

Vessels Interdicted

Migrants Interdicted at Sea

Migrants Interdicted Ashore

Injured

MEDEVAC'd

Deaths

Migrants Repatriated

5. Sorties/Patrols Summary (List of Sorties Since Last Report)

Air Since Last Report Total

Number of Sorties/Patrols

Area Covered (square miles)

Total Time On-Scene (In Hours)

Surface Since Last Report Total

Number of Sorties/Patrols

Area Covered (square miles)

Total Time On-Scene (In Hours)

6. Use of Force Summary

Category Since Last Report Total

III - Soft Empty Hand Control

IV - Hard Empty Hand Control

V - Intermediate Weapons

VI - Deadly Force

VSL - Force to Stop Vessel from Cutter/Boat

A/C - Force to Stop Vessel From Aircraft

Arrests

Seizures

Deaths

7. Operational Controls Summary

Currently In Force

Type Initiating Unit Initiated Date Activity #

Removed Since Last Report

Type Initiating Unit Initiated Date Date Removed Activity #

18. Prepared by:

Date/Time Prepared:

UNIT LOG ICS 214-CG (Rev 6/05)

1. Incident Name


From: To:

UNIT LOG ICS 214-CG

3. Unit Name/Designators

4. Unit Leader (Name and ICS Position)

5. Personnel Assigned

NAME ICS POSITION HOME BASE

6. Activity Log (Continue on Reverse)

TIME MAJOR EVENTS



1. Incident Name


From: To:

UNIT LOG (CONT.) ICS 214-CG

6. Activity Log (Continue on Reverse)

TIME MAJOR EVENTS

7. Prepared by: Date/Time:


UNIT LOG (ICS FORM 214-CG) Purpose. The Unit Log records details of unit activity, including strike team activity or individual activity. These logs provide the basic reference from which to extract information for inclusion in any after-action report. Preparation. A Unit Log is initiated and maintained by Command Staff members, Division/Group Supervisors, Air Operations Groups, Strike Team/Task Force Leaders, and Unit Leaders. Completed logs are submitted to supervisors who forward them to the Documentation Unit. Distribution. The Documentation Unit maintains a file of all Unit Logs. All completed original forms MUST be given to the Documentation Unit. Item # Item Title Instructions 1. Incident Name Enter the name assigned to the incident. 2. Check-In Location Enter the time interval for which the form applies. Record the start and end

date and time. 3. Unit Name/Designators Enter the title of the organizational unit or resource designator (e.g., Facilities

Unit, Safety Officer, Strike Team). 4. Unit Leader Enter the name and ICS Position of the individual in charge of the Unit. 5. Personnel Assigned List the name, position, and home base of each member assigned to the unit

during the operational period. 6. Activity Log Enter the time and briefly describe each significant occurrence or event (e.g.,

task assignments, task completions, injuries, difficulties encountered, etc.) 7. Prepared By Enter name and title of the person completing the log. Provide log to

immediate supervisor, at the end of each operational period. Date/Time Enter date (month, day, year) and time prepared (24-hour clock).

1. Incident Name


From: To:

AIR OPERATIONS SUMMARY ICS 220-CG

3. Distribution Fixed-Wing Bases Helibase

4. Personnel and Communications 5. Remarks (Spec. Instructions, Safety Notes, Hazards, Priorities)

Air Operations Director Air / Air Frequency Air / Ground Frequency

Air Operations Director

Air Tactical Supervisor

Air Support Supervisor

Helicopter Coordinator

Fixed-Wing Coordinator

6.

Location / Function

7.

Assignment

8. Fixed-Wing

9. Helicopter

10. Time

11. Aircraft

Assigned

12. Operating

Base NO. TYPE NO. TYPE Available Commence

13. TOTALS

14. Air Operation Support Equipment

15. Prepared by Date / Time

AIR OPERATIONS SUMMARY ICS 220-CG (Rev.07/04)

1. Incident Name


From: To: DEMOB. CHECK-OUT

ICS 221-CG

3. Unit / Personnel Released

4. Release Date / Time

5. Unit / Personnel You and your resources have been released, subject to signoff from the following: (Demob. Unit Leader “X” appropriate box(es)) Logistics Section

Supply Unit

Communications Unit

Facilities Unit

Ground Unit Planning Section

Documentation Unit Finance / Admin. Section

Time Unit Other

6. Remarks

7. Prepared by: Date / Time

DEMOB. CHECK-OUT ICS 221-CG (Rev.07/04)

DEMOB. CHECK-OUT (ICS 221-CG) Purpose. This form provides the Planning Section information on resource releases from the incident. Preparation. The Demobilization Unit Leader or the Planning Section initiates this form. The Demobilization Unit Leader completes the top portion of the form after the resource supervisor has given written notification that the resource is no longer needed. Distribution. The individual resource will have the unit leader initial the appropriate box(es) in item 5 prior to release from the incident. After completion, the form is returned to the Demobilization Unit Leader or the Planning Section. All completed original forms MUST be given to the Documentation Unit. Item # Item Title Instructions 1. Incident Name Enter the name assigned to the incident. 2. Operational Period Enter the time interval for which the form applies. 3. Strike Team / Unit / Enter name of Strike Team, Unit or personnel being released. Personnel Released 4. Release Date/Time Enter date (month, day, year) and time (24-hour clock) of anticipated

release. 5. Strike Team / Unit / Demobilization Unit Leader will enter an "X" in the box to the left of those Personnel units requiring check-out. Identified Unit Leaders are to initial to the right

to indicate release. NOTE: Blank boxes are provided for any additional unit requirements as needed, (e.g., Safety Officer, Agency Rep., etc.)

6. Remarks Enter any additional information pertaining to demobilization or release (e.g., transportation needed, destination, etc.).

7. Prepared By Enter name and title of the person preparing the form. Date/Time Enter date (month, day, year) and time prepared (24-hour clock).

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